Blank Salary Reduction Form

If you prefer not to complete the fillable SRA Form on this page, don't enter any information on this page, and click the ‘Generate BLANK SRA Form’ button below, complete the form by hand, sign, date, and deliver to Tillamook:

Fillable Salary Reduction Agreement

By entering your information into the fillable form below, and then clicking the 'Generate Printable SRA Form' button, you will generate a printable Salary Reduction Form which should be printed out, signed by you, and then submitted to Tillamook
with documentation that you have established an account with each selected Vendor:

Your Information

Your Name, Address, and Contact information is required.

Name

Street Address

Apt, Suite, or Unit (if applicable)

City

State

Zip

Telephone (home or mobile)

Email

Social Security Number

Agent Name and Telephone (If Applicable)

Effective Dates

Implementation: This Salary Reduction Agreement (the 'Agreement') supersedes any previous Salary Reduction Agreement for the person named below (the "Employee") under the 403(b) Tax Sheltered Annuity Plan (the "Plan") offered by School District No. 9, Tillamook County, Oregon (the "Employer"), also known as Tillamook School District. The salary reduction specified in this agreement will begin with the first paycheck on or after the "Effective Begin Date" specified below, provided this form is received by the Employer before the Payroll cutoff date for that paycheck. This Agreement will remain effective until a new Agreement is submitted.

Begin Date

Employee's Details:

Select the Appropriate Type of Agreement Below:

Replace/Override a Previous 403(b) Plan Salary Reduction Agreement

Start/Initiate a Very First (new) 403(b) Plan Salary Reduction Agreement

Distribution Among Vendors

If selecting a new Vendor, you MUST include documentation that an account has been established with the new Vendor that is linked to Tillamook. Vendor accounts linked to former employers may not be used for contributions at Tillamook. Tillamook allows you to contribute to a maximum of 2 different vendors. If Replacing/Overriding a Previous Salary Reduction Agreement or Starting/Initiating a New Salary Reduction Agreement, you must select at least one Vendor.
Finally, if this is one of 5 forms to be submitted as a group to establish an Active Payroll Slot for a new Vendor, then select "Other" from the pull-down box and write in the Vendor Name on the printed version of the form (all 5 forms should be submitted to CCC).

$ Traditional Dollars per Paycheck$ Roth Dollars per Paycheck

$ Traditional Dollars per Paycheck$ Roth Dollars per Paycheck

Clicking the button below will Generate a printable PDF form populated with the information entered above. You must still sign, date, and submit the form to
Tillamook
: